Bailouts During Neurointervention; Novel Techniques in Tackling Coil Migration and Premature Intravascular Detachment of Microcatheter Tip.

BACKGROUND: Intracranial vascular malformations are increasingly being treated via the endovascular route. Though generally safe, a multitude of intraprocedural complications that potentially lead to disastrous clinical outcomes may arise. It is crucial for the operators to be well versed with the various techniques that are available to overcome any procedure-specific complications. METHODS: We present 2 cases in which we encountered premature intravascular detachment of the microcatheter tip and coil migration while treating a dural arteriovenous fistula and aneurysm, respectively. We used a stentriever to remove the detached microcatheter tip and suction using the reperfusion catheter to remove the migrated coil, both techniques that have not been reported in the literature thus far. RESULTS: Detached microcatheter tip and migrated coil were successfully retrieved using a stentriever and aspiration catheter. CONCLUSIONS: These novel techniques could potentially reduce mortality and morbidity associated with neurointervention.

Stent-assisted coiling in ruptured cerebral aneurysms: multi-center experience in acute phase.

INTRODUCTION: The purpose of this study is to report on a multi-center experience of ruptured intracranial aneurysms treated in acute phase with stent-assisted coil embolization, including primary success rates and midterm follow-up results. MATERIALS AND METHODS: Retrospective analysis was performed on a sample of 40 patients (14 men, 26 women, mean age 59.7 years) affected by ruptured saccular aneurysms and treated by stent-assisted coiling in acute phase; double antiplatelet therapy with clopidogrel bisulphate and acetylsalicylic acid was started after the procedure. Angiographic follow-up at 1 year was recorded. RESULTS: 20 % of the aneurysms were located in the posterior circulation, and 85 % presented a wide neck. Mean size of the sac was 7 mm (range 3-22 mm). Complete sac exclusion was obtained in 92.5 % and neck remnant in 7.5 %. The overall complications rate was 15 %. In 7.5 %, stent occlusion occurred intra-procedurally. In 12.5 %, re-bleeding was detected within 3 weeks after the procedure. Ischemic area related to the procedure was observed at follow-up in 7.5 %. Hydrocephalus developed in 15 %. 7.5 % presented with sac re-bleeding between 1 and 5 months after the procedure. In 15 %, the 3-6 months of follow-up revealed aneurysm refilling. 25 % of the patients presented vessel stenosis at the 1-year DSA of control. 33 % of the patients reported sensory-motor deficits. 82.5 % had a favorable outcome (GOS: IV-V), while 17.5 % presented a poor score (GOS: I-III). CONCLUSIONS: Stent-assisted coil embolization is a feasible endovascular treatment option for ruptured intracranial aneurysms, which is difficult to approach with simple coiling; however, neurointerventionalists need to consider a mild increase of post-procedural complications rate.

Ruptured, dissecting posterior inferior cerebellar artery aneurysms: endovascular treatment without parent vessel occlusion.

INTRODUCTION: Treatment of a dissecting aneurysm of the medullary segments of the posterior inferior cerebellar artery (PICA) usually entails trapping of the diseased arterial segment with possible sacrifice of brainstem perforators. The goal of the work was to review our experience with selective coiling of ruptured, dissecting aneurysms of the anterolateral segments of the PICA without parent vessel occlusion. METHODS: Eleven consecutive patients (9 women, 2 men, mean age 47.2 years) were retrospectively reviewed from a prospectively acquired neuroradiological database. On admission three patients had Hunt and Hess (HH) grade I, three HH grade II, two HH grade III, and one HH grade IV. Outcome was evaluated according to the modified Rankin scale (mRS) score. Follow-up (mean:19.4 months) consisted of magnetic resonance angiography and/or digital subtraction angiography in ten patients. RESULTS: Ten patients had mRS score 0 and one mRS score 2. No treatment failure occurred. The aneurysm was completely occluded in seven patients, a neck residue was present in two, and a loose coil mesh was present in two. Recurrence occurred in three patients, and all were successfully retreated for a total of 13 procedures. Procedure-related complications were all without clinical consequences and included a coil perforation in one procedure and stagnant filling of the parent vessel in six procedures. PICA occlusion did not occur in any patient. CONCLUSION: Coiling of ruptured, isolated dissecting aneurysms of the PICA without parent vessel occlusion is feasible, relatively safe and effective in preventing early/medium-term rebleeding. A strict angiographic follow-up program is, however, necessary to detect recurrence.